2019 NENIC Member-Highlights Combined-Final€¦ · 1.CAUTI –Catheter Associated Urinary Tract Infection Risk or Actual – Adult/Pediatric 2.CLABSI –Central Line Associated Bloodstream

Nurses Transforming Healthcare Through Informatics

NENIC

Posters!


NENIC Member Highlights2019

1. Laura Ritter-CoxDeveloping an Intensive Care Unit Acuity Tool

2. Danielle PerleyAssessment, Creation and Adoption of a Sepsis Trigger Tool in the EHR

3. Mary Ellen KinnealeyUtilizing the Electronic Health Record in the Perioperative Arena in the Prevention of Pressure Injuries

4. Sarah WrightImplementation of Digital Whiteboard & Interactive Patient Education and Care Application

5. Naomi MercierImproving User Efficiency with Plan of Care Automation



Developing an Intensive Care Unit Acuity Tool Laura Ritter-Cox, MSN, RN-BCICU Application Administrator

Beth Israel Deaconess Med Center

DEVELOPING AN INTENSIVE CARE UNIT ACUITY TOOLLaura Ritter-Cox, MSN, RN-BC

NENIC

April 26, 2019

INTRODUCTION

Ø Patient acuity refers to the physical and

psychological complexity of patients

Ø The Therapeutic Intervention Scoring System 28

(TISS – 28) was developed to stratify patients by severity of illness

Ø Data from the electronic medical record can

automatically calculate the TISS – 28 score

Ø Massachusetts law requires all ICUs to have an acuity

tool 5

Goal

Ø In accordance with Massachusetts General Law

regulating nurse to patient ratios in critical care units,

we developed a tool and process to approximate

acuity and guide patient assignments using bio-

psycho-social assessment measures

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Robert Lombardo MS, RN, CCRNSharon O’Donoghue DNP, RNLaura Ritter-Cox MSN, RN-BCMoore Grant Nurse ConsultantsMoore Grant Work GroupsKeith Dietz MHSA, MMISAyad ShammoutAriel Mueller MAAcuity Tool Committee Members

ICU Dashboard

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Ø The dashboard is used to ensure each unit is staffed appropriately

Ø The scores are only a guide and provide an objective measure to support nursing judgement while making patient assignments

Ø Patient conditions are dynamic and acuity measurement is static and only valid at the time it is measured

Ø Nursing judgement is still utilized ultimately for assignments

Ø With changing technology, constant oversight is required Ø Reiterative training to assure all users are entering data

consistently

Results / Lessons Learned

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Next StepsØAssess the need for further user education to ensure

documentation accuracyØReview how this acuity tool is being used and evaluate

areas for improvement ØReexamine the TISS-28* weighting of therapies ØPossibly interfacing with other scoring systems ØAssessing the skill mix and acuity of each ICU to better

manage allocation of resources

References: Massachusetts Rule 958 CMR 8.00 - Bulletin HPC-2015-04, ICU Nurse Staffing Quality Measures.

Katz, A, Andres, J, Scanlon, A. (2018). Application of Therapeutic Intervention Scoring System

(tiss) to an Electronic Health Record: A Feasibility Study. Pediatrics. DOI:

10.1542/peds.141.1_MeetingAbstract.321.

Contact info: [email protected]

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Assessment, Creation and Adoption of a Sepsis Trigger Tool in the EHRDanielle Perley, BSN, RN, CPHON

Clinical Informatics SpecialistBoston Children’s Hospital

Assessment, Creation and Adoption of a Sepsis

Trigger Tool in the EHR

Danielle Perley, BSN, RN, CPHONClinical Informatics Specialist

Boston Children’s Hospital

• One million patients diagnosed with sepsis each year2

– Increasing awareness– Increasing vigilance– Quick diagnosis

• Surviving Sepsis Campaign– Focus on identifying and providing quick appropriate

care– Latest guidelines published in 20161

• Opportunity for inappropriate testing and treatments3

Introduction

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Assessment/Methods

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Request made to build Sepsis Trigger Tools in the EHR

Key Components to Clinical Decision Support Tools• Increase awareness• Protect patient from excessive testing/diagnostics4

Initial Wave for Electronic Sepsis Trigger Tools:• Intensive Care Units• General Medical Floors

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Assessment/Methods• Assess original paper tools used for pilots

Assessment/Methods

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• Sepsis Trigger Tool Built in the EHR– Build within nursing’s current workflow– Create a custom section in the flowsheet

which included:• Conditional logic• Selection based calculations• Discrete fields with interpretation capability

– 72 different interpretation scenarios built to accommodate all documentation possibilities for the ICU Sepsis Trigger Tool

Electronic Flowsheet BuildIntensive Care Unit Sepsis Trigger Tool

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The “Risk for Sepsis?” field is interpretive, it will interpret the 72 answer combinations for the previous fields for the tool and automatically determine if the patient is at risk for sepsis.

Fields denoted by a star are linked to reference text to provide clinical decision support the nurse

This field opens the appropriate Sepsis Trigger tool for the patient location

Assessment/Methods

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EHR Utilization in Additional Areas• Neonatal Intensive Care Unit

• New specialized tool• Dialysis/Therapeutic Apheresis

• Utilizing existing acute care tool

Discussion/Conclusion• Tool usage is monitored the initial adoption

areas– Intermittent chart audits– Data collection through our data warehouse– Included in our specialty views, including our new

Illness Severity View.• Sepsis Trigger Tools have been integrated into

policy– Help to ensure it is being used to capture early signs

of sepsis.

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References1. The Society of Critical Care Medicine (2018) Surviving Sepsis Campaign: Guidelines. Retrieved from

http://www.survivingsepsis.org/Guidelines/Pages/default.aspx2. Backer D.D., Dorman, T. (2017). Surviving Sepsis Guidelines: A Continuous Move Toward Better Care of

Patients with Sepsis, Journal of the American Medical Association, 317(8), 807-808. doi:10.1001/jama.2017.0059

3. McCulloh, R.J., Fouquet S.D., Herigon, J., Biondi E.A., Kennedy, B., Kerns, E. ,… Newland, J.G. (2018). Development and implementation of a mobile device-based pediatric electronic decision support tool as part of a national practice standardization project. Journal of the American Medical Informatics Association, 25(9), 1175–1182. https://doi-org.proxy.hsl.ucdenver.edu/10.1093/jamia/ocy069

4. Hussaain S., Dewey J., & Weibel, N. (2017). Reducing alarm fatigue: exploring decision structures, risks, and design, European Alliance for Innovation Endorsed Transactions on Pervasive Health and Technology, 17(10). http://dx.doi.org/10.4108/eai.13-7-2017.152886

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Contact Info• Email:

[email protected]

• LinkedInwww.linkedin.com/in/danielle-perley

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mailto:[email protected]



Utilizing the Electronic Health Record in the Perioperative Arena in the Prevention of Pressure Injuries

Mary Ellen Kinnealey, RN , MSHIPerioperative Informatics Staff Specialist

Massachusetts General Hospital


Utilizing the Electronic Health Record in the Perioperative Arena in the Prevention of Pressure Injuries

M. Ellen Kinnealey, RN, MSHIPamela Wrigley, RN, MS

Nurses Transforming Healthcare Through Informatics24

Introduction/Background� Pressure injuries (HAPI) cause devastating physical and emotional impact for

patients and research demonstrates that many hospital-acquired injuries originate in the operating room (OR).

� The incidence rate ranges from 12% to 66% � The length of surgery is a significant factor. � Patient safety literature supports the hand off communication of intraoperative

patient positioning. It is a mystery to most floor nurses how the patient is positioned in the OR.

� Our project team devised a way to communicate visually the OR positioning and potential pressure injury areas electronically.

� Using EPIC functionality, “Annotated Image,” developed unique enhancements.� The result is a shared drive with files of structured images of patient positions with

arrows highlighting areas of potential pressure injury.



Methods

� This project involves the entire MGH OR staff (250 RN’s) entering the annotated image for all surgical patients and procedures, seven days a week.

� Baseline PI prevalence rate from the OR was collected from the hospital-wide PI prevalence survey.

� Prior to implementation, education included staff meeting demonstrations and tip sheet development for OR and inpatient staff.

� To encourage project compliance, members of the Skin Injury Prevention committee were recruited to provide at-the-elbow support.

� A post implementation survey was sent to the OR staff to determine clinician satisfaction and the ease of use.

� Data is currently being collected via daily random audits of 10 procedures a day along with run chart trend analysis.


Results: Annotated Image Entered in OR Record


Discussion/Conclusion

� This quality improvement project provides nurses electronically with an image which communicates potential skin areas that may be at risk for pressure injury due to length of surgery and intraoperative positioning.

� Implementing evidence-based nursing interventions for example, turning and repositioning post-operatively, will help prevent skin breakdown and potentially avoid a pressure injury.



Implementation of Digital Whiteboard & Interactive Patient Education and Care Application

Sarah A. Wright RN, MSNNursing Informatics SpecialistNantucket Cottage Hospital


Implementation of Digital Whiteboard & Interactive Patient Education and Care

Application

Sarah Wright, RN, MSN

Clinical Informatics Specialist


Introduction and Background� With the recent completion of a new hospital, Nantucket Cottage Hospital (NCH)

evaluated the advantages of utilizing new digital technology to replace the standard dry erase whiteboard in the patient rooms.

� The standard board was historically updated manually with patient demographics, key vitals, and care team information and would often lag behind with up-to-date information.

� NCH chose to implement a hardware and software solution in 14 patient rooms.

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Goals

� Digitize patient information from the whiteboard and integrate it with the electronic health record (EHR).

� Assign patient education on various topics in both English and Spanish.

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Methods

� On-site demos from the vendor� Workflow observations and discussions with nursing staff� Interdisciplinary meetings with clinical management, information

technology and NCH senior leadership to reach final user interface design

� Prioritization of education videos based on most frequent diagnosis and labor and delivery patient specific needs

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Results� Whiteboard was live at the moment we welcomed the first patient into her

room� Content was integrated so updates in the EHR are viewed in real time� The patient pillow speaker is integrated with the TV controls, as well as the

nurse call system� Nurses are able to work with each patient to “bookmark” health focused

topics addressing individualized education needs

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49” Smart T.V. Displays

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Discussion and Conclusion� The NCH Clinical Business and Technology team is working closely

Partners eCare EHR clinical teams to identify further patient specific information for display

� DocFlowsheet interface - clinical information such as Pt goals, pain scores, icons for falls, activity limitations and newborn/mother data will be pulled realtime into the patient screens

� Further work is planned to map available educational videos to commonly chosen Plan of Care education interventions

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Improving User Efficiency with Plan of Care AutomationNaomi Mercier, DNP, RN

Clinical Content LeadPartners Healthcare

Improving User Efficiency with Plan of Care Automation

Naomi Mercier DNP, RN, Traynor Canny MBA, Courtney Green, RN, MS, Mary Hudson MS, RN, Christine Suchecki MSN, RN, Mary Swenson MBA, RN

Partners Healthcare Boston MA

Department Name Confidential – do not copy or distribute 39

Introduction/Background

• Evidence supports the automation of nursing care plans in the EHR• The Partners Healthcare Nursing Informatics Council prioritized nine patient

problems to automate • The problems selected directly align with National Patient Safety Goals and

NDNQI measures. 1. CAUTI – Catheter Associated Urinary Tract Infection Risk or Actual –

Adult/Pediatric2. CLABSI – Central Line Associated Bloodstream Infection, Risk or

Actual – Adult/Pediatric3. Fall Risk – Adult4. Fall Risk – Pediatric5. Pain, Acute/Chronic – Adult/Pediatric6. Pressure Injury – Adult/Pediatric 7. Restraint Use – Adult/Pediatric8. Suicide/Self-Harm- Adult/Pediatrics9. Venous thromboembolism Risk or Actual – Adult/Pediatric


Methods

Streamlining Problems for Automation:• Three, 2-hour Clinical Content Build-Out (CCBO) sessions were held to

review, update and streamline the content• Subject matter experts from each entity and a variety of inpatient settings

participated.• Software limitations in the 2015 version of the system did not allow users

customize goals and interventions before the problem populated the Plan of Care.

• Subject matter experts focused on including the minimum necessary goals and interventions for each problem.

Development of Automation Criteria:• The clinical informatics team applied an Agile framework for this effort. • User workflows were evaluated to define appropriate decision support

inclusion and exclusion criteria logic to automate each problem. • Logic for this automation include a specific order, assessment, patient class,

and encounter type.


Results

• The nine problems automate for most patients during their hospital encounter. • Requests to automate additional plans of care continue to be submitted and

evaluated. • The problem automation count correlate with the patient department.• Perioperative departments have higher counts for CLABSI and CAUTI

problems due to the number of assessments they enter for urinary and central catheters. Problem Count Department with Highest

CountFall Risk 9594 (Adult)

171 (Pedi)NSM Davenport 9 SH (230)MGH Ellison 18 Pedi (42)

Pain, Acute / Chronic 8895 MGH Perioperative (483)Pressure Injury, Risk or Actual 8055 NSM Davenport 9 SH (222)CAUTI, Infection Risk or Actual 4805 MGH Perioperative (986)CLABSI, Infection Risk or Actual 2719 BWH Perioperative (221)Venous Thromboembolism (VTE) Risk orActual

2426 BWH Perioperative (232)

Restraint Use 816 MGH Lunder 6 Neuro ICU (53)Suicide/Self-Harm Risk 94 MGH Ellison 18 Pedi (6)Skin/Wound Integrity - Skilled NursingFacility

79 SRB 1st Floor (37)


Discussion/Conclusion

• End user feedback is positive overall • Nurses have evidence that their documentation and the system’s decision

support is used build a relevant plan of care • Automation saves clicks and streamlines documentation • Concerns have been voiced that the automatically generated plans of care lack

patient individualization. • Design changes are being implemented to allow personalization of the plan of

care from the Best Practice Advisory alert. • Future work includes additional automation based on specific patient criteria.• End user feedback and analytics inform iterative adjustments to the decision-

support logic

Reference:

Agile Alliance: https://www.agilealliance.org/agile101/

https://www.agilealliance.org/agile101/

Documents

2019 NENIC Member-Highlights Combined-Final€¦ · 1.CAUTI –Catheter Associated Urinary Tract Infection Risk or Actual – Adult/Pediatric 2.CLABSI –Central Line Associated Bloodstream